International Journal of Nursing Studies
Volume 46, Issue 12 , Pages 1537-1540, December 2009

The art and science of mental health nursing: Reconciliation of two traditions in the cause of public health

King's College London, Florence Nightingale School of Nursing and Midwifery, James Clerk Maxwell Building, 57 Waterloo Road, SE1 8WA, London, UK

R&E Consultant, Office for Public Management, UK

Article Outline

Keywords: Mental health nursing, Health promotion, Public health, Positive psychology

 

We have argued elsewhere (Norman and Ryrie, 2009a) that the identity of mental health nursing in the UK and other developed countries has been shaped by a creative tension between two traditions – an ‘artistic’ interpersonal-relations tradition which emphasizes the centrality of nurses’ therapeutic relationships with ‘people’ ‘in distress’ and a ‘scientific’ tradition concerned with delivery of evidenced-based interventions that can be applied to good effect by nurses to ‘patients’ suffering from ‘mental illness’. In this editorial we outline these traditions and make the case for drawing on both to develop a new public mental health nursing role.

The origins of the interpersonal relations tradition is as old as mental health nursing itself, dating back to the ‘moral treatment’ philosophy established by 18th Century reformers such as William Tuke in the Retreat in York in 1792. Tuke replaced physical constraints with moral constraints based on reason supported by purposeful work and social and educational activities in a domestic environment. Fast forward 150 years to Hilda Peplau who, to the best of our knowledge, coined the term ‘nurse-patient relationship’ and whose book Interpersonal Relations in Nursing, first published in 1952 (Peplau, 1991) became a classic. Mental health nursing for Peplau involves nurses working through the medium of their relationship with patients (service users, clients) to create conditions that promote health and develop patients’ ability to engage with those around them. Peplau's ideas were promoted and developed by a number of British nurses amongst whom Annie Altschul and Phil Barker were particularly influential and the interprofessional relations tradition finds current expression in Barker's Tidal Model of nursing (http://www.tidal-model.com).

The ‘scientific’ evidenced-based practice tradition in mental health nursing also has a long history, but has emerged particularly strongly over the past 20 years supported by government policy on mental health services, both in the UK and internationally. This tradition reflects increasing confidence in scientifically proven methods for treating mental illness. It reflects too an assumption that mental health care practices are not sufficiently evidenced based and that nurses, amongst others, do not stick faithfully to evidenced based procedures when working with patients. In the UK Kevin Gournay, from his base in King's College London's Institute of Psychiatry, was a vociferous exponent of this tradition. Gournay had little time for ‘nursing models’ on the grounds that they do not reflect the reality of nursing and impede multi-disciplinary approaches to care and treatment. For Gournay and others in the evidenced based practice tradition a good relationship between the nurse and patient is taken for granted, for without this the patient is unlikely to take the nurse's advice. But this relationship is just one aspect of treatment and not a priority for study in its own right. The priority was to extend nurses’ work to incorporate roles occupied formerly by doctors and psychologists so they can contribute fully to deliver evidenced based interventions to patients, and to evaluate the effectiveness of these roles using rigorous scientific designs.

Who could object to promoting mental health nursing interventions that are proven to work as opposed to those which may not? However, some nurses in the interpersonal relations tradition remain unconvinced. As Barker (2009), puts it:

Many nurses are encouraged to believe that they need to develop ‘new’ skills or learn ‘new’ therapeutic models, in order to become effective in mental health care. The Tidal Model challenges such assumptions … Nursing originally meant to offer nourishment. Nothing has changed across the centuries. Today, people in mental distress need the nourishment that nursing can offer. They need the human support that will help them deal more effectively with the tidal forces which have rocked their lives. They need help to gain the confidence to get back in the boat and push off, from the shore, to begin again the journey on their ocean of experience.

In spite of Barker's reservations, in the early years of the present decade the position of mental health nurses in the evidenced based tradition appeared unassailable. Indeed, when the first edition of the Art and Science of Mental Health Nursing (Norman and Ryrie, 2004) was published it looked like nursing in the interprofessional relations tradition was in danger of being eclipsed. However, this has not happened and it seems to us that mental health nursing as a discipline, certainly in the UK and possibly internationally too, is more united than it has been for the past 20 years.

A key development which has gathered pace over the decade is the orientation of mental health policy towards the goals of promoting social inclusion and recovery, reducing social stigma and supporting the exercise of choice in meeting patient-centred goals. As a result most mental health interventions are framed within a recovery oriented approach. By ‘recovery’ we refer to an approach to mental health care which goes beyond managing symptoms to helping people rebuild or, where possible, retain a valued and satisfying life, by doing the things that they want to do and leading the lives they want to lead (see Perkins and Repper, 2009). Recovery oriented practice involves nurses working closely with patients through the medium of their relationships to help them achieve their goals.

Evidence for endorsement of recovery oriented mental health nursing practice in the UK comes from the 2006 Chief Nursing Officer's (England) review of mental health nursing (Department of Health, 2006), (the CNO's Review) which sought to answer the question: How can mental health nursing best contribute to the care of service users in the future? Publication of the CNO's Review was marked by publication of a Special Issue of the International Journal of Nursing Studies (IJNS) focused on mental health, which included a series of research and review papers which highlighted initiatives in contemporary mental health nursing practice, policy and education many of which demonstrated nurses drawing upon both the art and science of nursing in their practice.

Published papers included, for example, an investigation of nurses’ views of containment measures (Bowers et al., 2007a) together with an international comparison of these measures (Bowers et al., 2007b), a study of surveillance by nurses in a community mental health teams of mothers who suffered from mental illness (Davies and Allen, 2007) and access to nurses in such teams (McEvoy and Richards, 2007), an international comparison of the education of mental health nurses (Nolan & Brimblecombe, 2007) and an evaluation of a computerized education intervention (Gega et al., 2007). The Special Issue included, also, some reviews which provided a synthesis of the evidence on: physical health problems experienced by people with mental disorder (Robson and Gray, 2007); policy guidance on how to promote diversity sensitive services (Owen and Khalil, 2007); user and carer involvement in training health professionals (Repper and Breeze, 2007); and interventions delivered by mental health nurses (Curran and Brooker, 2007).

Also published in this Special Issue of the IJNS were the results of a national consultation conducted as part of the CNO's Review (Brimblecombe et al., 2007), which showed that many nurses were enthusiastic about their relationships with patients but also about developing new roles and skills and applying these in a ‘recovery oriented’ way through the medium of these relationships. These findings were reflected in the recommendations of the CNO's Review which described an approach to mental health nursing practice based on broad mental health policy which promoted patient centred goals, a recovery approach and evidenced based practice.

In his Guest Editorial in the Special Issue Brooker (2007) was critical of the CNO's Review for being high on aspiration but ‘desperately thin on detail on implementation’ and for failure to acknowledge the challenges of implementing values such as recovery, equity and social inclusion in practice. In response Brimblecombe and Tingle (2007) argued that the challenges of implementation, such as how nurses can offer patients choice at the same time as fulfilling their professional responsibilities, are best left to clinical nurses and their managers rather than be the subject of national recommendations. However, preliminary findings from the first stage of an evaluation of the impact of the CNO's Review provide some support for Brooker's concerns. The evaluation found that in spite of ranking highly the importance of adopting Recommendations 1 (Applying Recovery Approach values) and 5 (Strengthening relationships with service users and carers) mental health service providers and universities have found these difficult to implement due to factors such as competing priorities, lack of funding, and staffing difficulties (Baker et al., 2008).

Moreover, whilst the CNO's Review endorses recovery oriented practice, which involves application of both the art and science of mental health nursing, it is true also that the traditional focus for mental health nursing in the UK, and in most other countries, has been the person with a mental disorder, albeit within the context of their family and friends. ‘Individualized care’ has been the ideal, driven by the widely adopted problem solving approach, known as the ‘nursing process’. But insights from public health and positive psychology raise the question of whether an individualized approach to recovery oriented practice is really sufficient.

We know from work by Friedli (2009) and others that mental disorder is closely associated with deprivation in all its forms; with unemployment, less education, low income and poor material standards of life. The nature of this relationship is a question of continuing debate in which mental disorder is considered either a cause or a consequence of inequality; social selection explanations assume that people who are mentally ill become poor, whereas social causation explanations suggest that people become mentally ill because they are poor. There is substantial empirical support for social selection explanations, which assume that people become mentally ill because they are not able to function and compete in the job market. But it is now clear that the contribution of social factors (e.g. selective diagnosis in which some social groups are at greater risk of receiving a stigmatising label than others, differential access to psychological therapies mediated by ability to pay, differential utilization of mental health services mediated by differing views on their trustfulness) in ‘causing’ mental disorder have been under-recognised (see Rogers and Pilgrim 2003).

Important too are insights from positive psychology, on the benefits of positive mental health or well-being. Keyes (2002) proposes a mental health continuum from languishing to flourishing in life. Those who are flourishing are enthusiastic about life, active and engaged with others and social institutions. In contrast those who are languishing are at increased risk for depression, suicide and physical illness. Of interest here is Rose's (1992) population based approach to health promotion which demonstrates that the prevalence of common diseases in the population is related to the underlying population mean of underlying risk factors. Applying this to mental disorder suggests that reducing the risk factors for mental illness in society will have the effect of reducing the number of people suffering from mental disorder, and reducing the proportion, who are languishing and so at high risk (Huppert, 2005).

What implications do these insights have for the future role of the mental health nurse? The present focus of mental health nurses on providing individualised care for people who have serious mental illness is and should continue to be important. Individualised care counters the tendency to batch treatment, which can so easily occur even in community settings, and those who are most seriously ill do need the most skilled nursing care. However, insights from the public health field and from positive psychology points to a rather broader role for mental health nurses of the future which involves them being much more active than currently in promoting mental health at the level of individuals and communities (see Norman and Ryrie, 2009b for further discussion).

In the UK this broader role is evident in key health and local authority policy strands. For example, a recent review of the British National Health Service (NHS Next Stage Review, Department of Health, 2008) requires local bodies (known as Primary Care Trusts) to commission comprehensive health, well being and prevention services in partnership with local authorities. It is recommended that these services focus on six key goals: tackling obesity, reducing alcohol harm, treating drug addiction, reducing smoking rates, improving sexual health and improving mental health. Related local authority policy guidance is presented in ‘Creating Strong, Safe, Prosperous Communities’ (HM Government, 2008) with its focus on what are referred to as Local Area Agreements, Joint Strategic Needs Assessments and the preparation of Sustainable Community Strategies.

The health, well being and prevention policy strands in UK health policy present key opportunities for public mental health nursing. A partnership approach is required through which the public and mental health service users are encouraged to take greater responsibility for their health and well being wherever possible, and to engage in behaviour change when indicated. However, the precise approach will differ in terms of the degree to which an individual or community is ready to make behaviour change. Nurses need therefore to understand a community's preparedness to change and to develop pathways or interventions for different stages of a change cycle.

Mental health nurses who have worked with behaviour change in the addictions and related fields will be familiar with Prochaska and DiClemente's (1986) trans-theoretical model of change. The model presents behaviour change as a process with five key stages from ‘pre-contemplation’, where behaviour is not seen as problematic, through to the ‘maintenance’ of any behaviour change that occurs. In turn, motivational interviewing has developed as a therapeutic approach that offers different types of intervention at different stages of the change cycle to motivate or ‘nudge’ people towards change (see Kipping, 2009 for further discussion). For example, there is little point in offering exercise classes if people are unaware of the need for exercise or live in a culture where such activity is frowned upon. Community engagement, lifestyle assessments and peer education may provide a more effective route to improved public health and well being.

Social psychologists and behavioural economists are now applying these approaches to whole communities through geo-demographic profiling and targeted pathway development. Mental health nurses are well placed to support this agenda with their working knowledge of behavioural change cycles and the psychology that underpins them. As we write, UK primary care trusts and local authorities are grappling to realise this knowledge in their public services and we would expect that equivalent bodies in other countries are engaged with the same agenda.

Closely related to this opportunity is the need to develop a range of interventions that support people and communities to move along the continuum from ‘languishing’ to ‘flourishing’. We have documented elsewhere the ways in which mental health can be supported, distinct from mental illness, at both the individual and community level (see Ryrie and Norman, 2009 for further discussion). Mental health nurses in the UK can use this knowledge to work in partnership with primary care trusts and local authorities to support the development of programmes and pathways, which are needed for the public but also for people with mental health problems and other conditions.

In the UK Local Strategic Partnerships (LSP) are the key mechanism by which these policy strands are to be implemented at the local level, which provide a platform for mental health nurses to make their contribution. There is now a clear strategic agenda and policy framework, certainly in the UK and in other countries too, for public mental health nursing to develop as a dedicated discipline. Nursing's operational positioning is of less importance than its operational practice, which will be through partnership working across and within LSPs, drawing on the art and science of their discipline to inform the design of innovative programmes and pathways. Equally however, there is a need for all mental health nurses to develop their awareness of the public mental health agenda. They may be required to advocate on behalf of patients to ensure that local health and well being strategies take account of their needs and provide real opportunities for recovery.

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PII: S0020-7489(09)00329-0

doi:10.1016/j.ijnurstu.2009.10.010

International Journal of Nursing Studies
Volume 46, Issue 12 , Pages 1537-1540, December 2009

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